A Dead-Wrong Approach

A Dead-Wrong Approach

ACCIDENT INVESTIGATIONS DIVISION

U.S. Army Combat Readiness Center

Background

An infantry company was tasked to plan and execute a squad-level fire and maneuver lane. The company set up assembly and sleeping areas a few hundred meters from the lane. The ammunition point NCOIC issued live and blank ammunition from the same table, where both types were stored during the conduct of the range. There also were some smoke munitions in the same area.

The company cycled the squads through the day walk-through and blank fires before the live fires began. The company commander was the range officer-in-charge (OIC), and the platoon leaders alternated as the range safety officer (RSO) as their individual platoons went through the lane. Their duties included informing range support of the changes via radio or telephone.

The platoon sergeants and the company first sergeant performed safety duties during the squad iterations, as well as leader and range responsibilities. The company commander briefed each squad at the start point before firing began. The brief was oriented toward the tactical aspects of the lane rather than a general briefing covering both tactical and accidental risks.

As daylight faded, the last few squads cycled through the lane. However, the unit wasn’t pressed for time to complete the iterations. The first platoon, second squad received their safety brief from the company commander when they arrived at the start point for their iteration.

The squad engaged the first objective, and the squad leader fired a few rounds from his M4 rifle. One of the squad members ran out of ammunition at the second objective, so the squad leader handed the Soldier a loaded magazine from his assault vest. Another squad member ran out of ammunition at the third objective and was handed the magazine from the squad leader’s M4. The squad leader then pulled an empty magazine from his vest and loaded it in his M4.

When the lane was completed, the squad leader didn’t clear his rifle properly, but the rest of the group cleared their weapons and were checked by team leaders within the squad. However, the safeties and RSO didn’t verify all weapons were cleared. The company commander asked if all weapons were cleared, and the group said yes. The Soldiers then loaded a bus for the assembly area.

Dusk was setting in as the squad arrived at the assembly area, so the company ate chow and began the transition to night-fire iterations. During this downtime, the squad leader had come off the range and tasked one of his Soldiers to remove a PEQ-2A laser aiming device from another Soldier’s weapon, an M240B machine gun, and install it on his (the squad leader’s) M4. (The M240Bs weren’t fired during the iterations.)

The squad leader handed his M4 to the Soldier, and neither performed weapons-clearing procedures. As the Soldier searched for a tool to remove the sight, the squad leader began talking with other company members. The Soldier installed the sight and began looking for his squad leader.

While searching for the squad leader, the Soldier ran into two other Soldiers talking about knife-fighting techniques with chem lights. The Soldier walked closer to the other Soldiers because he wanted to join the conversation, but he raised the M4 from the low ready to firing position. He then pointed the rifle at one of the Soldiers and, in one fluid motion, rotated the selector lever to fire and squeezed the trigger. The Soldier to whom the rifle was pointed was hit in the face with a bullet.

The other Soldiers immediately began administering first aid and called range support and 911. However, different company members called 911 and range support at the same time, causing some conflict in response. The emergency responders also were delayed because of problems getting an accurate description of the situation and the Soldiers’ location. The injured Soldier finally was transported by ambulance to a local hospital, where he was pronounced dead.

Why the accident happened

· The squad leader didn’t verify his assigned M4 was cleared of all rounds in contravention of Field Manual 3-22.9, Rifle Marksmanship M16A1, M16A2/3, M16A4 and M4 Carbine; Soldiers Training Publication (STP) 21-1, Soldier’s Manual of Common Tasks; and local installation policies. He then gave the loaded weapon to another Soldier. The squad leader was preoccupied with his leadership responsibilities and forgot to complete his required personal actions.

· The RSO didn’t verify Soldiers exiting the range had cleared their weapons in accordance with STP 21-1 and local installation policies, allowing the squad leader to take a loaded weapon back to the assembly area. This failure was due to the RSO’s overconfidence in the Soldiers’ abilities to verify all weapons were cleared, a lack of formal local certification training, and improper supervision by the range OIC.

· A Soldier pointed a weapon he believed wasn’t loaded at another Soldier and pulled the trigger in contravention of local installation policies. This action was the result of personal indiscipline and overt complacency with respect to weapons handling.

· The company commander, who was acting as the range OIC, allowed procedures violations to happen within his formation. He attempted to simultaneously carry out the duties of observer/controller, OIC, RSO, and commander, but he didn’t ensure the personnel actually charged with those responsibilities accomplished the required tasks. The commander’s actions were in contravention of Army Regulation 385-63, Range Safety, and local installation policies. This failure was the result of overconfidence in his abilities to directly influence multiple range procedures simultaneously and his focus on the training’s tactical aspects.

Other observation. There was an unnecessary time lapse in the initial calls for emergency care and confusion regarding the information to convey.

What can be done?

· Unit training must be improved to ensure weapons handling and clearing procedures are followed and enforced at all times. Positive command action also should be taken to ensure proper personnel are selected as RSOs and that these individuals understand their duties and responsibilities.

· Commanders must ensure all personnel in key range positions are trained adequately to perform their assigned duties. This includes a review of existing local certification training programs and placing special emphasis on RSO duties and responsibilities.

· Commanders must emphasize how complacency and personal indiscipline can lead to accidents and severe or fatal injuries. They must enforce all applicable weapons handling procedures and expand unit training programs to overcome complacency and discipline shortcomings.

· Commanders must ensure range OICs understand their assigned duties and responsibilities and conduct effective primary marksmanship instruction before every range. In addition, all leaders must understand and practice Composite Risk Management.

· Soldiers at all levels should rehearse the casualty evacuation plan to determine if any shortcomings exist and take measures to correct deficiencies. Seconds can make the difference between life and death for an injured Soldier.

Comments regarding this article may be directed to the U.S. Army Combat Readiness Center (CRC) Help Desk at (334) 255-1390, DSN 558-1390, or by e-mail at . The Accident Investigations Division may be reached through CRC Operations at (334) 255-3410, DSN 558-3410, or by e-mail at .

Hey, Sir, What Are You Doing?

ACCIDENT INVESTIGATIONS DIVISION

U.S. Army Combat Readiness Center

Have you ever had an NCO ask you this question? And you replied, “Don’t worry, I’ve got it.” Chances are that NCO was trying to tell you something and maybe even offer some assistance. Teaming with NCOs seems like a fundamental practice all officers should follow, but three recent accidents indicate some officers are attempting to perform tasks traditionally accomplished by NCOs. The most recent of these accidents illustrates what can happen when an officer attempts to do it all.

A recent accident investigation revealed the company commander was attempting to simultaneously perform the duties of range officer in charge, range safety officer (RSO), and observer/controller. His divided attention resulted in several procedure violations, including a failure to ensure the actual RSO verified all weapons were clear before departing the range for the assembly area. As a result, one weapon was carried back to the assembly area with a round in the chamber. Later that day, the weapon was handled improperly and a Soldier was killed.

Although the company commander didn’t personally carry the weapon off the range, his actions contributed to the accident. While every Soldier has the responsibility to clear his weapon before departing the range, had the commander teamed with his NCOs in three distinct areas—division of duties, planning, and Composite Risk Management (CRM)—this accident might’ve been prevented.

NCOs x (Duties + Planning + CRM) = Combat Readiness

Effective partnering with NCOs provides an efficient and effective division of duties, which allows everyone to pay the correct amount of attention to their administrative, procedural, and leadership activities. Empowering NCOs with authority commensurate to these duties is essential, because it allows them to become stakeholders in their unit’s performance.

NCOs also should be involved in planning processes. Experienced NCOs can contribute immensely during the planning of any operation, from a weapons qualification range to a complicated squad or platoon live-fire maneuver lane. Your NCOs will bring a priceless gift to the planning table—experience. On average, NCOs at the company level have between 4 and 5 years of additional time in service. Officers must allow their NCOs to fulfill their roles in the training plan and enforce the standards.

Finally, NCOs must participate in the CRM process. NCOs have a unique perspective and, therefore, can see things officers often overlook. NCOs can validate tactical hazards and controls, as well as greatly assist in the identification of accidental hazards and development of relevant and actionable controls.

As officers, we like to think we can do it all, but we can’t. Your NCOs don’t just prepare promotion packets and grade PT tests. Empower and involve them in the planning and execution of training. Their involvement will enhance training value, ensure adherence to standards, and add to your unit’s credibility. Finally, involve your NCOs one step further in the CRM process. Their involvement will make the process real and demonstrate to junior Soldiers that CRM is worth doing.

Complacency: It’s a Killer

CSM FRANKLIN G. ASHE

Headquarters, 3rd U.S. Army

Fort McPherson, GA

It’s one thing to say a Soldier died leading his troops in combat or was killed putting other lives before his own. It’s another, however, to say a Soldier died because complacency and a lack of safety were tolerated in his or her unit. In fact, it’s downright unacceptable.

Soldiers put themselves and their buddies in jeopardy every time they fail to buckle their seatbelts, wear their helmets properly, or maintain muzzle awareness. No particular safety issue is more important than another, whether on duty or off, in garrison or in theater. Yet most accidents have at least one or two factors in common: complacency and/or leadership failures.

Leadership and safety can’t be separated. We don’t practice safety in addition to our other tasks; rather, it’s a vital part of what we do. Leaders are supposed to accomplish their missions and take care of their Soldiers. But they sometimes get so wrapped up in the mission part, they forget about the safety aspect.

Leaders must ensure they and their Soldiers conduct all their business in a safe manner. Enforcing correct troop-leading procedures is one way to accomplish this goal. However, leaders must be careful because, if they don’t pay attention to what they’re doing, they might unintentionally reinforce bad habits. They can’t allow themselves or their Soldiers to become complacent. For example, when leaders think they’ve talked too much about safety or pre-checks, they’re complacent. Nothing is routine, and you can’t place too much emphasis on safety.

Some Soldiers think being in a combat zone justifies doing things they’d never do in garrison. This attitude is deadly, and Soldiers are dying because of it. Leaders must train their Soldiers to follow proper steps and procedures according to their checklists—without taking shortcuts—on every mission. It’s their responsibility to stop and correct improper behavior when they see something isn’t quite right, regardless the mission.

Mission importance and OPTEMPO are easy excuses for taking shortcuts. We must make sure our young Soldiers and leaders don’t develop an attitude of “Hey, I’m not going to get hurt. I’ve done this before and nothing happened.” Soldiers and leaders should think about how much time they’ll lose if their equipment is destroyed or the individuals using it are gone for good, all in the name of saving a little time. The consequences don’t justify the means. The last thing anyone wants to do is kill their best friend because they weren’t paying attention or because they took a shortcut.

Being a senior leader, I become angry when I hear about Soldiers dying in preventable accidents or because of carelessness. Families back home wake up in the morning and go to bed at night worrying about their loved ones. Their worry is the enemy, but accidents are just as deadly as an improvised explosive device or small-arms ambush. All too often, parents and spouses are told by a casualty assistance officer or chaplain their loved one was killed in a situation that didn’t have to happen. There aren’t words to describe the devastation—it’s just senseless. I’ve thought about this hundreds of times, and it’s always in the back of my mind when I talk with the families of my Soldiers killed in action.

We don’t have to accept these losses. The best way we can honor those that have died is to do the right thing and save other Soldiers. Nobody is immune to complacency, but everyone is responsible for safety, regardless their rank or position. We all have the right to wave the red flag when there’s a safety problem—in fact, we’re obligated to say something! Sometimes we have to go out of our way, but I’d rather be tired and stop a Soldier from doing something wrong than be wide awake at a memorial service. There are no second chances then.